Travelers' diarrhea (TD) is a stomach and intestinal infection experienced during travel to a new location as a result of lack of immunity to local food-borne pathogens. TD is defined as the passage of unformed stool (one or more by some definitions, three or more by others) while traveling. It may be accompanied by abdominal cramps, nausea, fever, headache, and bloating. Occasionally dysentery may occur. Most travelers recover within three to four days with little or no treatment. About 12% of people may have symptoms for a week. Bacteria are responsible for more than half of cases, typically via foodborne illness and waterborne diseases. The bacteria enterotoxigenic Escherichia coli (ETEC) are typically the most common except in Southeast Asia, where Campylobacter is more prominent. About 10 to 20 percent of cases are due to norovirus. Protozoa such as Giardia may cause longer-term disease. The risk is greatest in the first two weeks of travel and among young adults. People affected are more often from the developed world. Recommendations for prevention include eating only properly cleaned and cooked food, drinking bottled water, and frequent hand washing. The oral cholera vaccine, while effective for cholera, is of questionable use for travelers' diarrhea. Preventive antibiotics are generally discouraged. Primary treatment includes rehydration and replacing lost salts (oral rehydration therapy). Antibiotics are recommended for significant or persistent symptoms, and can be taken with loperamide to decrease diarrhea. Hospitalization is required in less than 3 percent of cases. Estimates of the percentage of people affected range from 20 to 50 percent among travelers to the developing world. TD is particularly common among people traveling to parts of Asia, the Middle East, Africa, Latin America, and Central and South America. The risk is moderate in Southern Europe, and Russia. TD has been linked to later irritable bowel syndrome and Guillain–Barré syndrome. It has colloquially been known by a number of names, including "Montezuma's revenge", "Turkey trots", "Bali belly" and "Delhi belly".
Signs and symptoms The onset of TD usually occurs within the first week of travel, but may occur at any time while traveling, and even after returning home, depending on the incubation period of the infectious agent. Bacterial TD typically begins abruptly, but Cryptosporidium may incubate for seven days, and Giardia for 14 days or more, before symptoms develop. Typically, a traveler experiences four to five loose or watery bowel movements each day. Other commonly associated symptoms are abdominal cramping, bloating, fever, and malaise. Appetite may decrease significantly. Though unpleasant, most cases of TD are mild and resolve in a few days without medical intervention. Blood or mucus in the diarrhea, significant abdominal pain, or high fever suggests a more serious cause, such as cholera, characterized by a rapid onset of weakness and torrents of watery diarrhea with flecks of mucus (described as "rice water" stools). Medical care should be sought in such cases; dehydration is a serious consequence of cholera, and may trigger serious sequelae—including, in rare instances, death—as rapidly as 24 hours after onset if not addressed promptly.
Causes
Infectious agents are the primary cause of travelers' diarrhea. Bacterial enteropathogens cause about 80% of cases. Viruses and protozoans account for most of the rest. The most common causative agent isolated in countries surveyed has been enterotoxigenic Escherichia coli (ETEC). Enteroaggregative E. coli is increasingly recognized. Shigella spp. and Salmonella spp. are other common bacterial pathogens. Campylobacter, Yersinia, Aeromonas, and Plesiomonas spp. are less frequently found. Mechanisms of action vary: some bacteria release toxins which bind to the intestinal wall and cause diarrhea; others damage the intestines themselves by their direct presence. Brachyspira pilosicoli pathogen also appears to be responsible for many chronic intermittent watery diarrhea and is only diagnosed through colonic biopsies and microscopic discovery of a false brush border on H&E or Warthin silver stain: its brush-border is stronger and longer that Brachyspira aalborgi's brush-border. It is unfortunately often not diagnosed as coproculture does not allow growth and 16S PCR panel primers do not match Brachyspira sequences. While viruses cause less than 20% of adult cases of travelers' diarrhea, they may cause nearly 70% of cases in infants and children. Diarrhea due to viral agents is unaffected by antibiotic therapy, but is usually self-limited. Protozoans such as Giardia lamblia, Cryptosporidium and Cyclospora cayetanensis can also cause diarrhea. Pathogens commonly implicated in travelers' diarrhea appear in the table in this section. A subtype of travelers' diarrhea afflicting hikers and campers, sometimes known as wilderness diarrhea, may have a somewhat different frequency of distribution of pathogens.
Risk factors The primary source of infection is ingestion of fecally contaminated food or water. Attack rates are similar for men and women. The most important determinant of risk is the traveler's destination. High-risk destinations include developing countries in Latin America, Africa, the Middle East, and Asia. Among backpackers, additional risk factors include drinking untreated surface water and failure to maintain personal hygiene practices and clean cookware. Campsites often have very primitive (if any) sanitation facilities, making them potentially as dangerous as any developing country. Although travelers' diarrhea usually resolves within three to five days (mean duration: 3.6 days), in about 20% of cases, the illness is severe enough to require bedrest, and in 10%, the illness duration exceeds one week. For those prone to serious infections, such as bacillary dysentery, amoebic dysentery, and cholera, TD can occasionally be life-threatening. Others at higher-than-average risk include young adults, immunosuppressed persons, persons with inflammatory bowel disease or diabetes, and those taking H2 blockers or antacids.
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